Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 38 Medical Errors PPT-Powerpoint Presentations and lecture notes
Medical and Surgical Errors
Dept. of Surgery
"Many doctors know the guilt, shame and self
doubt that occur when patients suffer a serious
complication or die due to a mistake made by
the clinician, healthcare team or health care
system"
? A 79 year old Male was on regular dialysis due
to CRF. Once while undergoing dialysis he
started having SOB. He was admitted to the
ICU and was managed. Next day he
complained of epigastric pain for which he
was prescribed antacid, which he received
from his nurse. Only........ It was'nt an antacid,
it was pancuronium!
Objectives
(1)To become familiar with common patient
safety definitions.
(2) To become familiar with the causes of
medical errors.
(3) To become familiar with the common types
of medical errors.
(4) To become familiar with recommendation
that help prevent adverse events/medical errors
in the healthcare system.
Patient Safety Definitions
? Medical error, defined as the failure of a
planned action to be completed as intended
or the use of a wrong plan to achieve an aim.
? Adverse event, defined as an injury caused by
medical management rather than by the
underlying disease or condition of the patient.
? Preventable adverse event, defined as an
injury that could have been avoided as a result
of an error or system design flaw.
? Ameliorable adverse event, defined as an injury whose
severity could have been substantial y reduced if
different actions or procedures had been performed or
followed.
? Negligence, defined as whether the care provided
failed to meet the standard of care reasonably
expected of an average physician qualified to take care
of the patient in question.
? Error of omission, occurs when a necessary procedure
or intervention failed to be performed leading to
morbidity or mortality to the patient involved.
Why do errors happen?
? Al humans make errors: indeed, "the ability to
make mistakes" al ows human beings to function
? Most of medicine is complex and uncertain
? Most errors result from "the system"--inadequate
training, long hours, ampoules that look the same,
lack of checks, etc
? Healthcare has not tried to make itself safe
EPIDEMIOLOGY
Epidemiology
? Medical errors are the
3rd leading cause of
death in the US.
? In India, 5.2 million
medical errors occur
annually.
TYPES OF MEDICAL ERRORS
? Misdiagnosis/delayed
diagnosis/overdiagnosis
? Unnecessary
tests/procedures
? Unnecessary treatment
? Medication errors
? "Never-events"
? Uncoordinated care
? HAIs
? "Not- so- accidental
accidents"
? Pressure ulcers
? Missed warning signs
? "Jholachaap" doctors
Failure to provide
prophylactic treatment
? Failure of
communication
RISK FACTORS
Risk factors
? Age
? Complexity of care
? Emergency or acute care
? Insufficient knowledge
? Ignorance of sources of error
? Low community spirit
? Clinician autonomy and low acceptance to
change
CAUSES
? "July effect"
? Poor communication
? Improper
documentation
? Illegible handwriting
? Inadequate nurse to
patient ratio
? Cost cutting measures
? Similarly
named/sounding
medicines
? Disconnected reporting
systems in the hospital
? Sleep deprivation
? Extreme specialization
? Logistic problems
? Equipment related
issues
? Unstructured discharge
summaries
MEDICATION ERRORS
Medication errors
? There are inherent risks associated with
therapeutic use of drugs.
? The hazards that result from such risk are
called drug-misadventuring, which includes
both ADRs and medication error.
? Episodes in drug misadventuring that should
be preventable through effective systems
control.
TYPES OF MEDICATION ERROR
? Prescribing error
? Omission error
? Wrong time error
? Unauthorized drug error
? Improper dose error
? Wrong dosage form
error
? Wrong administration
technique error
? Deteriorated drug error
? Monitoring error
? Compliance error
CAUSES OF MEDICATION ERROR
Causes of medication error
? Look alike/sound alike
? Illegible handwriting
? Inaccurate dose calculation
? Inadequately trained personnel
? Inappropriate use of abbreviations
? Labelling errors
? Excessive workload
? Medication unavailable
SURGICAL ERROR
? It is a preventable
mistake during surgery.
Surgical errors go
beyond the known risk
of surgery.
TYPES OF SURGICAL ERROR
? Nerve injury
? Wrong site
? Wrong patient
? Wrong procedure
? Wrong equipment
? Surgical souvenirs!
? Anaesthesia errors
CAUSES OF SURGICAL ERROR
Insufficient
Incompetence
preop planning
Improper
Fatigue
surgical
techniques
Poor
communication
The Second Victim
? Is the physician that
cared for the patient.
? Implications for the
second victim: -
? Emotional and
psychological
? May result in a career
change
? May destroy the
reputation and career
How to think of error?
? An individual failing
? Blaming them for carelessness, forgetfullness
? Wil not solve the problem--Doctors wil
hide errors
? It is often the best people who make the
worst mistakes
? Mishaps tend to occur in recurrent patterns
How to think of error?
? A systems failure
? This is the starting point for redesigning the
system and reducing error.
? Team work
? Better communication
? Evidence based practice
PREVENTION
INTERNATIONAL PATIENT SAFETY
GOALS(IPSG)
MISCONCEPTIONS
? "Bad apples" are a common cause- faulty
process of care delivery is more common.
? High risk procedures are responsible for most
avoidable errors- surgical errors are harder to
conceal, but errors occur at all levels.
Bottom line
? Fallibility is part of the human condition
? We can't change the human condition but
we can change the conditions under which
people work.
? Naming, blaming and shaming have no
remedial value
? We need to design health care systems that
put safety first (First, do no harm)
? These goals highlight problematic areas in health
care
? Describe evidence-based and expert-based
consensus solutions
? It is essential that EVERYONE should be familiar
and able to incorporate into daily practice
IPSG 1-Identify Patients Correctly
Two-fold Intent :
? FIRST, to identify the individual as the person
for whom the service or treatment is intended.
? SECOND, to match the service or treatment to
that individual.
IPSG 1-Identify Patients Correctly
? Patients must be identified using "two unique
identifiers" i.e. FULL NAME and CRN
? MUST NEVER use patient's room or location
to identify patient.
? ALWAYS ask the patient / guardian / parent to
verbalize patient's name whenever possible
IPSG 2- IMPROVE EFFECTIVE
COMMUNICATION
Verbal medication orders are reserved for code/emergency
situations ONLY.
? When receiving a medication telephone order from a
physician:
? Nurse A writes the order in the physician order sheet.
? Nurse B will read back the order written by Nurse A to the
physician.
? The prescriber will verify the order is correct to Nurse B.
? Both Nurse A and Nurse B must document the date and
time the order was received, badge number of the
prescriber, and their own names, job title and badge
numbers and both must sign the order sheet.
IPSG 2- IMPROVE EFFECTIVE
COMMUNICATION
? Reporting critical results of diagnostic tests.
? The technologist/reporter wil provide the report to the Receiver
(Requesting Physician/Ward Nurse).
? The receiver wil document (hand -WRITE) the critical results.
? The receiver (or another person - could be another nurse) wil READ
BACK the information provided, including the patient's medical
record number and name to the reporter.
? The technologists/reporter wil verify the information is correct.
? Both the reporter and the receiver must document the READ BACK
verification procedure was carried out; date and time the report
was received, badge number of the person providing/receiving the
report.
IPSG 2- IMPROVE EFFECTIVE
COMMUNICATION
? Handovers of patient care:
? During shift changes
? Between different levels of care
? From in-patient units to diagnostic units
IPSG 3-Improve the Safety of High-
Alert Medications
? Medications that pose an increased risk of
causing significant harm to patients if used in
error.
? Independent double checks in handling is one
of the safety measures.
? Look alike & Sound alike
IPSG 4- Ensure Correct-Site, Correct-
Procedure, Correct-Patient Surgery
? UNIVERSAL PROTOCOL:
1.Marking the surgical site
2.Pre-operative verification
3. Time out
Marking the surgical site
? made by the person performing the procedure
with a permanent skin marker.
? takes place with the patient AWAKE and AWARE,
if possible.
? to be done in al cases involving laterality (right,
left), multiple structures (fingers, toes, lesions) or
multiple levels or region (spine).
? be done using an instantly recognizable mark
(ARROW) that is consistent throughout the
hospital.
TIME OUT ? Pause with a purpose
? full verification that is performed immediately prior to the
induction of Anaesthesia or the start of an invasive
procedure
? the entire care team actively and verbally confirms:
? Patient's identity (two identifiers)
? Procedure to be performed
? Correct procedure side/site
? Necessary imaging, equipment, implants or special
requirements are present
IPSG 5- Reduce the Risk of HAI
? 5 moments of hand hygiene
? Before patient contact
? Before aseptic task
? After body fluid exposure
? After patient contact
? After contact with patient surroundings
? Wash hands with soap and water when hands
are visibly soiled.
? Use alcohol-based hand rub when hands are
not visibly soiled
IPSG 6- Reduce the Risk of Patient
Harm Resulting from Falls
? Upon initial admission assessment, Physicians
should screen Patient's Functional status
which include "FALL RISK".
? Functional Screening should be documented in
the Physicians History and Physical form
complimented by nurses' assessment.
? Communicate to nurses for implementation.
SUMMARY
Bottom line
? Fallibility is part of the human condition
? We can't change the human condition but
we can change the conditions under which
people work.
? Naming, blaming and shaming have no
remedial value
? We need to design health care systems that
put safety first (First, do no harm)
MISCONCEPTIONS
? "Bad apples" are a common cause- faulty
process of care delivery is more common.
? High risk procedures are responsible for most
avoidable errors- surgical errors are harder to
conceal, but errors occur at all levels.
This post was last modified on 08 April 2022